Citation Nr: 21074570 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 19-30 774 DATE: December 15, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for bilateral chronic conjunctivitis is denied. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is denied. Entitlement to service connection for asthma is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. FINDINGS OF FACT 1. The Veteran's bilateral chronic conjunctivitis manifests as impaired visual acuity of no worse than 20/40 in the right eye and no worse than 20/40 in the left eye; without impaired visual fields, incapacitating episodes, or disfigurement. 2. The probative evidence of record is against finding that the Veteran has had COPD at any time during or approximate to the pendency of the claim. 3. The probative evidence of record is against finding that the Veteran has had asthma at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 10 percent for bilateral chronic conjunctivitis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.79, Diagnostic Code 6018. 2. The criteria for entitlement to service connection for COPD are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for asthma are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1971 to March 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2018 rating decision. The above issues were remanded by the Board in May 2020 for further development. Increased Disability Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Entitlement to a disability rating in excess of 10 percent for bilateral chronic conjunctivitis is denied. The Veteran's bilateral chronic conjunctivitis is rated 10 percent disabling under 38 C.F.R. § 4.79, Diagnostic Code 6018, for chronic conjunctivitis (nontrachomatous). For the reasons discussed below, the Board finds that an increased disability rating is not warranted. Soon after the Veteran filed his claim for an increased disability rating, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Thus, because the rule went into effect prior to the Veteran's claim, the Board will only consider the new rating criteria. The revised criteria distinguishes active and inactive disease processes. Under the revised criteria, an active disease process is rated pursuant to the General Rating Formula for Diseases of the Eye, with a minimum rating of 10 percent. For an inactive disease process, the revised criteria instructs to evaluate based on residuals, such as visual impairment and disfigurement (Diagnostic Code 7800). The General Rating Formal for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, Diagnostic Codes 6061-6091. The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75(a). Examinations of visual impairment must be conducted by a licensed optometrist or ophthalmologist, and the examiner must identify the disease, injury, or other pathologic process for any visual impairment found. Id. § 4.75(b). Examinations of visual field or muscle function will be conducted only when medically indicated. Id. Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Generally, the table is divided into steps corresponding to different levels of visual acuity for one eye, and each step is further divided into subsections of visual acuity for the other eye, with corresponding ratings. The rater will first locate the step that matches the visual acuity of the poorer eye. Within that step, the rater will then locate the subsection that matches the visual acuity of the better eye, which will produce the corresponding rating. Where a reported visual acuity is between two sequentially listed visual acuities, the visual acuity which permits the higher evaluation will be used. 38 C.F.R. § 4.76(c). To evaluate the severity of the Veteran's bilateral chronic conjunctivitis, he was afforded several examinations. A July 2018 Eye Conditions Disability Benefits Questionnaire states that the Veteran has diagnoses of allergic conjunctivitis bilaterally and that its course is itchy and irritation, nuclear sclerosis bilaterally, migraine headache, arcus senilis bilaterally, and pinguecula bilaterally. The examination report states that the Veteran was previously diagnosed with allergic conjunctivitis, but there were no signs or complaints of such on the date of the examination. The Veteran's diagnoses of nuclear cataracts, arcus senilis, and pinguecula are new and unrelated entities that developed since the last examination or a diagnosis that was not identified previously. The Veteran's cataracts and arcus are age-related and unrelated to any previous disabilities. Pinguecula is related to UV exposure and not related to any previous disabilities. The July 2018 examination report provides that the Veteran's corrected distance vision was measured as 20/40 bilaterally. He does not have a difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision, with the near vision being worse. The July 2018 examination report states that the Veteran's pupils are 4 millimeters bilaterally. His pupils are round and reactive to light and there is not an afferent pupillary defect present. He does not have anatomical loss, light perception only, or extremely poor vision or blindness of either eye. He does not have a corneal irregularity that results in severe irregular astigmatism. He does not have diplopia. His right eye pressure was measured at 14 and left eye pressure at 13. The July 2018 examination report provides that the Veteran's slight lamp and external eye examination was abnormal. He demonstrated bilateral pinguecula in the conjunctiva/sclera, 1+ arcus in the cornea bilaterally, and tr to 1+ nuclear sclerosis in the lens bilaterally. The Veteran's internal eye examination was normal. The July 2018 examination report demonstrates that the Veteran has a documented visual field defect and has contraction of a visual field. The examiner described the Veteran's visual fields using a Goldmann's equivalent III/43 target. The visual field for the right eye was 12 degrees up, 12 degrees up nasally, 18 degrees nasally, 10 degrees down nasally, 20 degrees down, 18 degrees down temporally, 30 degrees temporally, and 10 degrees up temporally. The visual field for the left eye was 5 degrees up, 12 degrees up nasally, 10 degrees nasally, 15 degrees down nasally, 20 degrees down, 20 degrees down temporally, 25 degrees temporally, and 18 degrees up temporally. He does not have a scotoma and he does not have legal blindness based upon visual field loss. He has cornea/conjunctiva conditions noted as pinguecula, arcus senilis that do not contribute to a decrease in visual acuity or other visual impairment. He has a lens condition noted as preoperative cataract without a replacement lens or aphakia or dislocation of the crystalline lens and there is no decrease in visual acuity or other visual impairment as a result. Lastly, he has a neuro-ophthalmic condition, described as ocular migraine headaches that most likely cause his visual field contraction. The July 2018 examination report states that the Veteran does not have scarring or disfigurement attributable to any eye disability. During the past 12 months, he has not had any incapacitating episodes attributable to any eye disability. His eye disabilities do not impact his ability to work. A September 2020 Eye Conditions Disability Benefits Questionnaire provides that the Veteran has diagnoses of age-related cataract, bilateral, arcus senilis, bilateral, pinguecula, bilateral, and dry eye syndrome, bilateral. He reported symptoms of tearing, itchiness, light sensitivity, burning bilaterally during episodes of conjunctivitis. Concerning treatment, the Veteran uses over-the-counter artificial tears. His corrected distance vision was measured as 20/40 bilaterally. He does not have a difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision, with the near vision being worse. The September 2020 examination report states that the Veteran's pupils are 4 millimeters bilaterally. His pupils are round and reactive to light and there is not an afferent pupillary defect present. He does not have anatomical loss, light perception only, or extremely poor vision or blindness of either eye. He does not have a corneal irregularity that results in severe irregular astigmatism. He does not have diplopia. His right eye pressure was measured at 15 and left eye pressure at 13. The September 2020 examination report demonstrates that the Veteran's slit lamp and external eye examination are abnormal as the Veteran has pinguecula nasal bilaterally, arcus senilis bilaterally, and 2+ nuclear sclerosis in the right eye and 1+ nuclear sclerosis in the left eye. His internal eye examination was normal bilaterally. The September 2020 examination report indicates that the Veteran does not have a visual field defect. He has dry eye syndrome bilaterally, without laser eye surgery that is treated with over-the-counter artificial tear drops and does not result in a decrease in visual acuity or other visual impairment. He also has pinguecula and arcus senilis as cornea/conjunctiva conditions, but that do not cause a decrease in visual acuity or other visual impairment as the disabilities are not on the visual axis. He has bilateral preoperative cataract, aphakia or dislocation of the crystalline lens is not present, and there is no decrease in visual acuity or other visual impairment as a result as the right eye cataract is moderate and the left eye cataract is mild and causes slight impairment in vision. The September 2020 examination report states that the Veteran does not have scarring or disfigurement attributable to any eye disability. Over the past 12 months, he has not had any incapacitating episodes attributable to any eye disability. His eye disabilities do not impact his ability to work. The September 2020 examination report indicates that the Veteran's cataracts, pinguecula, dry eye syndrome, and arcus senilis are unrelated to the service-connected diagnosis. His pinguecula is most likely a result of long-term UV exposure, resulting in degeneration of the conjunctiva. His arcus senilis are peripheral degeneration of the cornea and most likely age related. His nuclear sclerotic cataracts are also age related. The Veteran's dry eye syndrome is a result of tear film insufficiency and dysfunction of his meibomian glands. The examination report states that these disabilities are not related to his conjunctivitis. Further, while the Veteran's records indicate that he was diagnosed with conjunctivitis, there are no signs or symptoms noted during the examination to confirm the diagnosis of conjunctivitis, thus showing that it may have resolved. Lastly, the September 2020 examination report provides that the Veteran's symptoms of itchiness, burning, tearing and light sensitivity may be related to his dry eyes and pinguecula. His complaints of blurry vision may be attributable to his cataracts. Since arcus senilis is an asymptomatic condition, the Veteran does not have symptoms associated to this diagnosis. The examination report concludes that the Veteran did not have physical signs and symptoms of conjunctivitis and the condition could not be objectively confirmed during the examination. Therefore, the diagnosis of chronic conjunctivitis cannot be warranted. The Veteran's VA treatment records also describe the severity of his bilateral chronic conjunctivitis. A May 2017 VA Eye Optometry Clinic Note states that the Veteran complained of decreased distance and near vision bilaterally, itching, and burning. The Veteran's vision was measured as right eye 20/20-1 and left eye 20/20. The Veteran was assessed with dry eyes bilaterally, early nuclear sclerosis, small left eye pterygium, and refractive error. A May 2018 VA Optometry Clinic Note states that the Veteran's eyesight has been stable. He uses over-the-counter reading glasses when reading and only has difficulty with very tiny print. He denied ocular pain and complained of tearing in his right eye more than his left eye. He denied a history of ocular surgery and denied use of ocular medications and eye drops. His eyesight was measured as right eye 20/25-2+ slow/push, left eye 20/20, and bilaterally 20/20-2 slow. A May 2019 VA Eye Optometry Clinic Note provides that the Veteran reported slight blurriness with distance and near vision. His vision improves when he removes his distance glasses. He has occasional left eye pain that is achy and have occurred for the past two months. He uses Refresh artificial tears to relieve his achy left eye pain. His vision was measured as 20/25-1 in the right eye and 20/50-1+2, pinhole 20/30+1. A May 2020 VA Eye Ophthalmology/Optometry Telephone Note provides that the Veteran denied vision changed bilaterally and had no other urgent eye issues. He complained of dry eyes. Additionally, the Veteran's claims folder contains a private Report of Consultation and Examination completed in May 2018 by P.J.Y, D.C, which provides his bilateral chronic conjunctivitis is chronic and persists to the present. Applying the facts in this case to the criteria set forth above, the Board finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for bilateral chronic conjunctivitis. Under the revised criteria, an active disease process is rated pursuant to the General Rating Formula for Diseases of the Eye, with a minimum rating of 10 percent. The evidence does not demonstrate that the Veteran had incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, thus necessitating a 20 percent disability rating under the General Rating Formula for Diseases of the Eye. The July 2018 examination report provides that the Veteran did not have signs or complaints of allergic conjunctivitis on the date of the examination. Additionally, the evidence contained in the September 2020 examination report indicates that the Veteran's bilateral chronic conjunctivitis did not have physical signs and symptoms of conjunctivitis, the condition could not be objectively confirmed during the examination, and the diagnosis of chronic conjunctivitis cannot be warranted. Thus, the Board has considered whether higher ratings are warranted based residuals, such as visual impairment or disfigurement. There is no evidence of disfigurement or scarring of the eyes. Therefore, a disability rating in excess of 10 percent under Diagnostic Code 7800 is also not warranted. 38 C.F.R. § 4.118. Additionally, the evidence shows that the Veteran's impaired vision is not attributable to his bilateral chronic conjunctivitis. Per the September 2020 examination report, the Veteran's itchiness, burning, tearing, and light sensitivity may be related to his dry eyes and pinguecula and his blurry vision may be related to his cataracts. Moreover, at worst, the Veteran's corrected distance visual acuity is 20/40 in both eyes. These findings are contemplated by a noncompensable disability rating; therefore, a disability rating in excess of 10 percent based on impairment of central visual acuity is not warranted. 38 C.F.R. § 4.79, Diagnostic Code 6066. Lastly, while the July 2018 examination report shows that the Veteran has contraction of visual field, it was related to his ocular migraines. 38 C.F.R. § 4.77 The Board has considered whether a higher disability rating is available under any other potentially applicable provision of the rating schedule. However, the Board finds that a higher rating is not warranted for his bilateral chronic conjunctivitis based on any other provision of the rating schedule at any time throughout the period of appeal. The preponderance of the evidence is against a disability rating in excess of 10 percent for the Veteran's service-connected bilateral chronic conjunctivitis. Therefore, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service Connection Service connection generally will be awarded when a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection on a direct basis, the evidence must show the following: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a link or nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 252 (1999). Additionally, VA has established a presumption of service connection for certain diseases found to be associated with herbicide exposure. See 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). Absent affirmative evidence to the contrary, such diseases will be service connected even if there is no evidence of the disease during service, provided that herbicide exposure is established. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(d), 3.309(e). The term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 (the Vietnam Era). 38 C.F.R. § 3.307(a)(6). A veteran who, during active military service, served in the Republic of Vietnam during the Vietnam Era is presumed to have been exposed to such herbicide agents. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6). Because the Veteran served in the Republic of Vietnam during the Vietnam Era, as shown by his receipt of the Vietnam Campaign Medal and Vietnam Service Medal, he is presumed to have been exposed to an herbicide agent. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6); see also Certificate of Release or Discharge from Active Duty. However, the Veteran's claimed COPD and asthma do not qualify for the presumption of service connection based on herbicide agent exposure under 38 C.F.R. § 3.309(e). Accordingly, service connection on a presumptive basis under § 3.309(e) cannot be established for the Veteran's COPD or asthma. Although presumptive service connection based on herbicide agent exposure is not available for the Veteran's claim for service connection for COPD or asthma, service connection may still be established with proof of direct causation. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (observing that the "availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange"); cf. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The requirement for a current disability is satisfied if the disability is present at any point proximate to the claim, during the claim, or to the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2014). If there is no evidence of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Additionally, there must be a demonstration of symptoms proximate to, or since, the time the application is filed. Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). Further, pain alone, even without an underlying pathology or diagnosis, can constitute a disability under VA law where such pain results in functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a "disability" under 38 U.S.C. § 1110 refers to functional impairment of earning capacity; pain need not be diagnosed as connected to a current underlying condition to function as an impairment.). 2. Entitlement to service connection for COPD is denied. The Veteran maintains that he has COPD that is related to exposure to contaminated and toxic air from burn pits during his active service. For the following reasons, the Board finds that service connection is not established. The initial threshold question for the Board is whether the Veteran has a current diagnosis of COPD or related functional impairment of earning capacity. The Board concludes that the record demonstrates that the Veteran does not have COPD and has not been shown to have had a diagnosis of one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 5107(b); Romanowsky, 26 Vet. App. at 294; McClain, 21 Vet. App. at 321; 38 C.F.R. § 3.303(a), (d). Further, there is no medical evidence of any abnormal findings related to the lungs or functional impairment on objective examination. See Saunders, 886 F.3d at 1367-68. The Veteran was afforded a September 2020 Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire. The Veteran reported that he cannot take a deep breath and as a result cannot perform strenuous activities such as ascending stairs and walking long distances. The examination report indicates that the Veteran does not have and has never been diagnosed with a respiratory disability and he does not have a pulmonary disability. The examiner provided that although the Report of Consultation and Examination completed in May 2018 by P.J.Y, D.C noted that the Veteran's respiratory difficulties manifest as chronic cough, wheezing, dyspnea, and sleep apnea and provided diagnoses of COPD and bronchial asthma based on auscultation of the Veteran's lung fields. The examination report states that although the Veteran's symptoms could be consistent with COPD and bronchial asthma, they manifest as sleep apnea. Further, there are no previous diagnostics available to review that would support a definitive diagnosis of COPD or bronchial asthma. While the Veteran reports the use of albuterol as needed, his records do not indicate a definitive diagnosis that would require the use of this medication. Therefore, the diagnoses of COPD and asthma are no longer warranted. Related, the Veteran was provided with a September 2020 chest X-ray that showed no acute intrathoracic process. An October 2020 pulmonary function testing (PFT) demonstrated that the Veteran's spirometry, lung volumes, and diffusion capacity were within normal limits. The stated "borderline decreased MVV maneuver" on the PFT is not clinically significant for Veteran per the September 2020 examination report. The Veteran's post-service VA treatment records reflect that his past medical history include COPD but does not indicate that the Veteran has a diagnosis of COPD based on diagnostic testing. As noted above, the Veteran's claims folder contains a private Report of Consultation and Examination completed in May 2018 by P.J.Y, D.C. The report states that the Veteran was exposed to contaminated and toxic air generated from burn pits in close proximity to his sleeping area. He developed respiratory difficulties during his active service, which have intensified over the years and now manifest as chronic cough, wheezing, dyspnea, and sleep apnea. On auscultation of the Veteran's lung fields, same is consistent with COPD. The examination report concludes that the Veteran's COPD is related to his active service. The Board finds that the determination of P.J.Y. that the Veteran has a diagnosis of COPD based on auscultation carries no probative weight. There is no evidence that as a chiropractor concerned with the diagnosis and treatment of mechanical disorders of the musculoskeletal system that he has the requisite medical training or expertise to make such a finding. Alternatively, the Board finds that the rationale in support of finding a diagnosis of COPD based simply on listening to the Veteran's lungs is inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its reasoning); Stefl, 21 Vet. App. at 124 ("[A] medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Board has considered the Veteran's claim that he has COPD and that it is related to his active service and finds that it lacks probative weight. In this regard, because the Veteran is not shown to have a medical background or expertise, he is considered a lay person in the field of medicine. Lay testimony is competent as to matters capable of lay observation or within a person's first-hand experience and may be competent evidence with respect to both the diagnosis of a medical condition and its etiology or cause. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Therefore, while the Veteran is competent to describe his symptoms of chronic cough, wheezing, and dyspnea, he is not competent to provide a medical diagnosis, such as COPD that requires the ability to interpret complicated diagnostic medical testing. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Further, the September 2020 examination report provides that the Veteran's symptoms are attributable to his sleep apnea. In sum, the preponderance of the evidence weighs against a finding of service connection for COPD. Accordingly, the benefit of the doubt doctrine is not for application, and the claim for service connection must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for asthma is denied. The Veteran maintains that he has asthma that is related to exposure to contaminated air from burn pits during his active service. For the following reasons, the Board finds that service connection is not established. The initial threshold question for the Board is whether the Veteran has a current diagnosis of asthma or related functional impairment of earning capacity. Again, the Board concludes that the record demonstrates that the Veteran does not have asthma and has not been shown to have had a diagnosis of one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 5107(b); Romanowsky, 26 Vet. App. at 294; McClain, 21 Vet. App. at 321; 38 C.F.R. § 3.303(a), (d). Further, there is no medical evidence of any abnormal findings related to the lungs or functional impairment on objective examination. See Saunders, 886 F.3d at 1367-68. The Veteran was afforded a September 2020 Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire. The Veteran reported that he cannot take a deep breath and as a result cannot perform strenuous activities such as ascending stairs and walking long distances. The examination report indicates that the Veteran does not have and has never been diagnosed with a respiratory disability and he does not have a pulmonary disability. The examiner provided that although the Report of Consultation and Examination completed in May 2018 by P.J.Y, D.C noted that the Veteran respiratory difficulties manifest as chronic cough, wheezing, dyspnea, and sleep apnea and provided diagnoses of COPD and bronchial asthma based on auscultation of the Veteran's lung fields. The examination report states that although the Veteran's symptoms could be consistent with COPD and bronchial asthma, they manifest as sleep apnea. Further, there are no previous diagnostics available to review that would support a definitive diagnosis of COPD or bronchial asthma. While the Veteran reports the use of albuterol as needed, his records do not indicate a definitive diagnosis that would require the use of this medication. Therefore, the diagnoses of COPD and asthma are no longer warranted. Related, the Veteran was provided with a September 2020 chest X-ray that showed no acute intrathoracic process. An October 2020 PFT demonstrated that the Veteran's spirometry, lung volumes, and diffusion capacity were within normal limits. The stated "borderline decreased MVV maneuver" on the PFT is not clinically significant for Veteran per the September 2020 examination report. In addition, consistent with the September 2020 examiner's findings and the diagnostic testing results, the Veteran's VA treatment records do not reflect a diagnosis related to asthma. As discussed above, the Veteran's claims folder contains a private report of consultation and examination completed in May 2018 by P.J.Y, D.C. The report states that the Veteran was exposed to contaminated and toxic air generated from burn pits in close proximity to his sleeping area. He developed respiratory difficulties during his active service, which have intensified over the years and now manifest as chronic cough, wheezing, dyspnea, and sleep apnea. On auscultation of the Veteran's lung fields, same is consistent with bronchial asthma. The examination report concludes that the Veteran's bronchial asthma is related to his active service. Again, the Board finds that the determination of P.J.Y., as a chiropractor concerned with the diagnosis and treatment of mechanical disorders of the musculoskeletal system, that the Veteran has a diagnosis of bronchial asthma based on auscultation carries no probative weight as there is no showing that he has the requisite medical training or expertise to make such a finding. Alternatively, the Board finds that the rationale in support of finding a diagnosis of bronchial asthma based simply on listening to the Veteran's lungs is inadequate. See Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124. The Board has considered the Veteran's claim that he has asthma and that it is related to his active service and finds that it lacks probative weight. In this regard, because the Veteran is not shown to have a medical background or expertise, he is considered a lay person in the field of medicine. Lay testimony is competent as to matters capable of lay observation or within a person's first-hand experience and may be competent evidence with respect to both the diagnosis of a medical condition and its etiology or cause. Davidson, 581 F.3d at 1316; Jandreau, 492 F. 3d at 1376-77. Therefore, while the Veteran is competent to describe his symptoms of chronic cough, wheezing, and dyspnea, he is not competent to provide a medical diagnosis, such as asthma that requires the ability to interpret complicated diagnostic medical testing. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Additionally, the September 2020 examination report provides that the Veteran's symptoms are attributable to his sleep apnea. In sum, the preponderance of the evidence weighs against a finding of service connection for asthma. Accordingly, the benefit of the doubt doctrine is not for application, and the claim for service connection must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Unfortunately, the Veteran's claim for service connection for sleep apnea must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim, so he is afforded every possible consideration. 1. Entitlement to service connection for sleep apnea is remanded. The Veteran's claim for service connection was remanded by the Board in May 2020 to afford him an examination and medical opinions to determine the nature and etiology of his sleep apnea. The Veteran maintains that his sleep apnea is related to his in-service exposure to contaminated and toxic air from burn pits or his service-connected posttraumatic stress disorder (PTSD). In particular, the examiner conducting the examination was directed to determine whether the Veteran's sleep apnea had its onset during his active service, is etiologically related to his active service, or is otherwise proximately due to his psychiatric disability. Subsequently, the Veteran was afforded a September 2020 Sleep Apnea Disability Benefits Questionnaire. The examination report states that the Veteran has a diagnosis of obstructive sleep apnea and the date of diagnosis is 2016. The Veteran reported that he uses a Continuous Positive Airway Pressure (CPAP) machine. A July 2016 sleep study conducted at the Orlando VA Medical Center showed that the Veteran has a diagnosis of obstructive sleep apnea. He does not have any current findings, signs, or symptoms related to sleep apnea per the examination report. A corresponding September 2020 medical opinion finds that the Veteran's sleep apnea is less likely than not incurred in or caused by his active service. In support, the medical opinion provides that the Veteran's records do not note treatment of symptoms related to sleep apnea during his time in service. The Board finds that the September 2020 medical opinion is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The medical opinion is based solely upon an absence of contemporaneous documentation of treatment of symptoms related to sleep apnea contained in the Veteran's service treatment records. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (holding that the absence of contemporaneous medical records does not, in and of itself, render lay testimony not credible); Cf. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that a VA opinion was inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on lack of evidence in service medical records to provide a negative opinion). Therefore, a remand is necessary to afford the Veteran a new medical opinion to determine the etiology of his sleep apnea. Regarding whether the Veteran's sleep apnea is caused by or aggravated by his service-connected PTSD, additional September 2020 medical opinions state that there is no medical evidence to link sleep apnea with a psychiatric disability. The etiology of sleep apnea is usually related to functions of the pulmonary or cardiovascular systems and not that of the psychological nature. The evidence contained in the Veteran's claims folder demonstrates that his sleep apnea may be caused by his obesity, which in turn is caused by his service-connected PTSD. VA's Office of General Counsel (OGC) issued a precedential opinion addressing questions regarding whether obesity may be considered a "disease" for the purposes of service connection under 38 U.S.C. §§ 1110 and 1131, and whether obesity may be considered a disability for purposes of secondary service connection. In general, the opinion concludes that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131 and, therefore, may not be service connected on a direct or secondary basis. VAOPGCPREC 1-2017 (January 6, 2017). However, the OGC opinion found that obesity can constitute an "intermediate step" for service connection on a secondary basis under 38 C.F.R. § 3.310(a). Id. Specifically, a grant is warranted (1) if the service-connected disability caused the veteran to become obese, (2) if obesity was a substantial factor in causing a subsequent disability, and (3) if this subsequent disability would not have occurred but for obesity. Id. Thus, there is a viable theory of entitlement to service connection for sleep apnea as secondary to the Veteran's service-connected PTSD. The above September 2020 medical opinions did not address the issue of whether the Veteran's sleep apnea may be secondary to his service-connected PTSD with an intermediate step of obesity linking the sleep apnea to the PTSD. See 38 C.F.R. § 3.310(a). Accordingly, a supplemental medical opinion is required to address this issue. The matter is REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from July 2020 to the present. 2. After the above development is completed, obtain a medical opinion concerning the etiology of the Veteran's sleep apnea. The examiner must review the Veteran's claims folder. The examiner must: (a.) Opine whether the Veteran's sleep apnea at least as likely as not (50 percent probability or greater) had its clinical onset during active service or is related to any incident of service, including reported exposure to contaminated and toxic air generated from burn pits in close proximity to his sleeping area. (b.) Opine whether the Veteran's sleep apnea is at least as likely as not related to in-service exposure to herbicide agents. The examiner is advised that a negative opinion cannot be based solely on the fact that the Veteran's service records do not note treatment of symptoms related to sleep apnea, and that the sleep apnea is not on the list of diseases that are presumptively associated with exposure to herbicide agents. The complete rationale for all opinions expressed must be set forth by the examiner. 3. Should service connection not be found on a direct basis, schedule the Veteran for a VA examination to determine the cause of his obesity. The examiner must review the Veteran's claims folder. The examiner must: (a.) Opine whether it at least as likely as not (50 percent probability or greater) that the Veteran's service-connected PTSD caused him to become obese. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 4. Next, if it is determined that the Veteran's service-connected PTSD caused him to become obese, obtain medical opinions concerning the relationship between his obesity and sleep apnea. No additional examination is necessary, unless the clinician determines an examination is necessary to provide the requested opinions. The examiner must review the Veteran's claims folder. The examiner must: (a.) Opine whether it is it at least as likely as not (50 percent probability or greater) that the Veteran's obesity was a substantial factor in causing his sleep apnea. (Continued on the next page) (b.) Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran's sleep apnea would not have occurred but for his obesity. The complete rationale for all opinions expressed must be set forth by the examiner. L. BARSTOW Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mussey, Sean The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.